Presenting To An Accident And Emergency Department With Abdominal Pain
5% of patients who visit accident and emergency complain of abdominal pain. Of 18% admitted there is actually non-specific abdominal pain. 12% is in the female pelvic area and 12% in the urinary tract. Furthermore, 9% is a gastrointestinal problem and 10% will require surgery.
Abdominal pain is particularly difficult to diagnose in women and the elderly.
Normally pain relief will be withheld until the cause of the pain is identified and a diagnosis is made. Often, however, there are relatively few specific diagnostic tests for abdominal pain, for example there is no specific test for appendicitis.
All too often the patient is told in the accident and emergency that they are suffering from constipation. It is important for all patients to remember that constipation is not necessarily a diagnosis but a symptom of a condition which should be diagnosed.
It is acceptable to diagnose constipation only if and when other diagnoses have been ruled out.
The competent clinician will consider the following when the patient presents to A & E:-
- The history of the abdominal pain
- The site of the pain
- The pain radiating elsewhere
- The nature of the pain
- Any aggravating factors
- Any relieving factors
- Gastrointestinal symptoms such as anorexia, nausea, vomiting, constipation and diarrhoea
- Urinary symptoms
- Past medical history
- Alcohol
- Blood pressure
- What drugs the patient is on
Examination
The clinician will then make a judgment as to whether the patient appears to be well or ill. He will also ask the patient whether they are still in pain and, if so, at what level. Vital signs will also be checked, namely temperature, blood pressure, pulse, respiratory rate and oxygen saturations.
However, it may be the case that all these signs are normal but all is not well. If the patient is still in pain and appears to be ill, a good standard would be to make 4 assessments of the vital signs at intervals to check there has been no deterioration.
Abdomen
The competent clinician will inspect the abdomen and then palpate it. A rectal examination may be made. The standard here should be that only 1 rectal examination is made and by someone who is experienced.
Investigations
These will include a full blood count looking for normal white cells; amylase which is a marker for pancreatitis; a liver function test and finally venous blood gas including lactate which is a marker of sickness.
Imaging
These will include:-
- a chest x-ray
- an abdominal x-ray
- ultrasound – this is a helpful tool as it shows freed fluid in the abdomen
- CT scan
- Angiography
COMMON PROBLEM AREAS
Appendicitis
This accounts for 1% of patients who are admitted with abdominal pain. The symptoms are the pain itself; anorexia, nausea or vomiting; a fever; a tender lower abdomen and a raised white cell count.
Appendicitis is a very difficult condition to diagnose and is commonly missed. Furthermore, the appendix is not always in the same place in a patient. A delayed presentation by the patient is common which can lead to a higher perforation rate if appendicitis is not diagnosed quickly. Only 20% of patients have classic symptoms and signs of appendicitis and abdominal x-rays are not particularly helpful.
Torsion Of The Testis
The symptoms of this in a male are:-
- Severe abdominal plus genital pain
- Vomiting
- Collapse
- On examination testis swollen and tender
However, there is a big risk with this condition that the patient is simply given antibiotics and sent home if the symptoms are not classic or severe enough.
Ectopic Pregnancy
If a female presents to A & E of child bearing age and with abdominal pain the clinician should be “thinking ectopic”. This is a serious and life threatening condition if not diagnosed quickly enough. It is often misdiagnosed as a urinary tract infection. The competent clinician will consider the following:-
- The previous history, namely previous ectopic pregnancies and/or pelvic inflammatory disease
- Classic pain and vaginal bleeding
- Hypotension
- Peritonism
- A positive pregnancy test
A gynaecological ultrasound will diagnose an ectopic pregnancy. The patient will need immediate intravenous antibiotics followed by surgery.
Elderly Patients
15% of those patients presenting to A & E are over 65. Of those, 30 – 40% require surgery and the mortality rate is 11 – 14%. Mortality is higher if there is an incorrect diagnosis.
The elderly are more often misdiagnosed in A & E than any other group of patients. This can be due to a combination of factors to include communication difficulties; delayed presentation to the A & E department; the elderly minimising their symptoms; complications caused by current medication and other related or unrelated conditions the patient might already be suffering from.
Sometimes an elderly patient can actually look well even though there is something seriously wrong with them. Elderly patients have 10x higher mortality compared with younger patients and higher rates of vascular causes of abdominal pain. If in doubt, a cautious clinician will admit an elderly patient for observation.
Abdominal Aortic Aneurysm
An abdominal aortic aneurysm is when the large blood vessel that supplies blood to the abdomen, pelvis, and legs becomes abnormally large or balloons outward.
This is a common area of misdiagnosis in up to 30% of patients.
The risk factors are as follows:-
- Male
- Aged 65 or over
- Family history
- A smoker
- Pre-existing arterial disease
- Hypotension
- Chronic obstructive pulmonary disease
The classic presentation is in a male with abdominal/flank pain. Other symptoms to look for are shock together with an abdominal mass. There will be retro peritoneal bleeding in up to 90% of cases usually to the left and back pain.
However, there may be atypical signs and symptoms which makes diagnosis extremely difficult. Common misdiagnoses are as follows:-
- Renal colic
- Pancreatitis
- Intestinal ischaemia
- Diverticulitis
- Cholecystitis
- Appendicitis
- Perforated viscus
- Bowel obstruction
- Musculoskeletal back pain
- Acute myocardial infarction
Fortunately, an ultrasound is 100% sensitive in detecting an abdominal aortic aneurysm.
Your doctor will examine your abdomen. The exam also will include an evaluation of pulses and sensation in your legs. The doctor may find:
- Abdominal mass
- Stiff or rigid abdomen
- Pulsating sensation in the abdomen
Mesenteric Ischaemia
This is where the blood supply to the bowel has been compromised.
It is essential to make an early diagnosis but, again, it is difficult to detect. It should always be considered in the elderly with abdominal pain who have additional risk factors. There is mortality of 70% if infarction occurs.
The signs of mesenteric ischaemia are:-
- Abdominal pain
- Abdominal distension
- Rectal bleeding
- Change in mental status
The absolutely key marker for this condition is the lactate level in the patient. It is a sensitive marker and should always be done as lactate rises early in mesenteric ischaemia although a normal lactate level does not rule out the condition. Serial lactate measurements are recommended rather than just relying on one level which is normal.
The next step will be for the patient to have a CT scan followed by surgery or the bowel will infarct and the patient will die.
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